Torticollis Impacting Oral Motor? March 1/ 2019 Laura Doyle, PT BHsc(PT). B. Ed., B. Kin

Contact for Laura Doyle- doylel@hhsc.ca

• Intro

• Torticollis

• Anatomy

• Assessment

• Tongue Tie?

Signs of torticollis may include any combination of the following symptoms:

• Preference to tilt head sideways towards one side

• Preference to turn face towards one side (Referring to past baby photos can

help parents recognize these postural preferences)

• Tightness and/or palpable mass in the SCM neck muscle (smaller than pea-size)

• Flattened area(s) on baby’s head (plagiocephaly)

• Ear, eye, cheek, jawline, and/or forehead on one side of face may be more

prominent or relatively shifted in position compared to the other side

• Lack of full end-range motion of neck turning or tilting towards one or both sides

• Trunk may appear to curve or arch sideways to one side

• Slow to acquire gross motor skills (tummy time, rolling etc.)

(Tatli, 2006)

Torticollis

Variety of causes

• constraint position or extreme head

posturing in the womb

• difficult or prolonged labor and delivery

• large birth weight and/or long birth length

• multiple births

• low amniotic fluid

• muscle damage at birth

• mass located in SCM

Sternocleidomastoid (SCM)

• two locations, the manubrium of

the sternum and the clavicle

• travels obliquely across the side of

the neck and inserts at the mastoid

process of the temporal bone of

the skull

• Function and ROM

• Digastric muscle- hyoid

Cranial Nerves

• -

• -

• -,.

• -

CN5 palate, tongue lower jaw, nose and mastication muscles- forceps

CN7 facial muscles, lips cheeks, jaw, suck, rooting

CN9,

CN10,

CN11

between temporal and occipital bones, palate, tongue, gag

response, mastication

CN11 controls the SCM and trapezius- therefore involved with torticollis,

head position, airway patency- affects suck, swallow and breathe

CN12 C section- surgeon lifting occiput at cranial base could disrupt

hypoglossal nerve which is responsible for anterior and posterior

tongue

- Consider myotome and dermatomal distribution

Anatomy Zone

Muscles used in Suckling

• Mastication and Suckling

– Temporalis

– Masseter

– Medial Pterygoid

– Lateral Pterygoid

– Buccincator

– Orbicularis Oris

– Mentalis

• Tongue Movement

– Genioglossus

– Styloglossus

– Stylohyoid

– Digastric

– Mylohyoid

– Hyoglossus

– Geniohyoid

– Intrinsic musculature of

tongue

Impacts?....so many

Positioning

• head and body facing breast – football hold

• correct latch- head reclined/ neck extension and their mouths wide open- chin to

breast and nose not touching

Ability to use muscles appropriately and sustain

• baby with torticollis may be unable to attain this position or maintain it

• Baby unable to draw milk from the breast efficiently

Supply

• not stimulating breast enough thus attributing to low milk supply

• Baby may latch in a way that causes pain to compensate for the inability to move

the tongue and jaw well.

BF - Function

• Hyoid function

• Asymmetrical jaw and tongue- impacts ability to pull milk

from the breast, ability to latch and sustain suck/suction

• Positioning- cross cradle vs football hold

• Supply varies significantly from one breast to the other

• Unilateral nipple damage/pain

Assessment- many layers

Joint Assessment

• Mom- goals, mechanics and positioning, supply, pain,

health (physio + BF assessment)

• Infant- body, neck, head positioning,

health, pain, weight gain

• Breastfeeding - infant and milk transfer

mechanics

Collaborative practice!

Baby • Feeding frequency

• Behaviour pre and post feeds

• Oral anatomy

– Lips, jaw, cheeks, tongue

– Strength and coordination of suck

• Position

• Latch

• Signs of effective milk transfer

• Physical assessment- neck, head, body

Physical Assessment

• Neck PROM ( general landmarks)

- Rotation- infants chin to the AC joint- goes past shoulder- hypotonicity?

- Side flexion- ear to shoulder

- Star Gaze- combined rotation and side

flexion with slight flexion- ear rests above nipple

• Neck AROM

- Changes with development

• Palpation SCM- for mass- location, thickness, insertions, general tone

-an ischemia or hemorrhage occurs within the SCM, which results in a muscular

compartment syndrome and eventual contracture of the SCM with secondary shortening

• Skull Symmetry- plagiocephaly, brachecephaly, scaphocephaly

• Jaw and oral motor cavity

Additional Assessment Items

• Resting position- supine, car seat, prone (photos), sleeping

• Hips- positive Ortolani (click)

• Other skeletal observations

• General muscle tone

• Righting reactions

• Palpation for mass

• Baby Equipment and use

• Gross motor assessment- ie. pull to sit, midline position of head

- amount of Tummy time !!!!!

Oral Motor

• Movement of tongue- elevate- whole

tongue to palate to create vacuum,

lateralize, cup V shape, peristalsis to

move bolus front to back, extend, tip

to palate

• Tongue resting position

• Oral restrictions- anterior tongue tie,

posterior tongue tie, buccal ties, lip

ties

• Sleeping – mouth open or closed

Breastfeeding Assessment- Atypical

• Clearest evidence of sucking problem is pain

• mis-shaped nipple, bruising, cracked or bleeding resulting from attempting to remove milk

• may also be seen as weak suck- baby slides off breast or short feed because of reduced flow of milk

• disorganized sucking patterns can result from altered ways to remove milk

• suck is difficult to assess accurately- refer to a lactation consultant

Other Feeding Clues… • Football vs cradle

• Unilateral nipple pain

• Low endurance on one side

• On/off breast not related to flow

• Milk supply

• Poor latch

• Tongue “bunching”

• Face/head shape

• Cannot extend neck symmetrically to latch

Unique Considerations

• A tight jaw—baby may be unable to open his mouth wide

enough to take the breast properly

• Clamping—baby may clamp down on the breast

• Restricted tongue movements causing bunching,

humping or retraction of the tongue

• A tendency to gag during feeding

Oral Restriction or Torticollis?

•

Sequella of Torticollis on Breastfeeding

• For baby:

Poor latch

Unable to sustain latch

Compromised or aggressive

Fatigue

Poor milk transfer

• For mom:

Painful latch

Blocked ducts, mastitis

Low milk supply

Key

1. poor removal = low supply

2. mom has pain or low supply= look at baby for facial tone, ROM of tongue, ROM neck

3. In utero growth & birth events can impact breastfeeding

4. refer to LC early- BANA, NAP, Public Health to protect milk supply

5. until dyad can be seen by LC protect milk supply by having mom remove milk efficiently by hand or pump 8x per day as babies may feed 8 or more times per day.

Tummy Time

Resources

• HHS Educational Pamphlet

“Congenital Muscular Torticollis”

• Seattle Children’s Hospital

“PE347 Torticollis and Your Baby”